How does pediatric care differ among the ER, urgent care, and retail clinics?

Your child is sick or injured. Where should you go?

Choosing the right healthcare facility is a complex decision. It balances concerns about treatment quality, cost, and timeliness. In the moment, finding that answer is too much to ask of any parent—the only concern is your child’s health.

But that doesn’t make choosing the right provider any less important. Understanding the differences now ensures that, in a stressful moment, you’ll have the confidence to make the right choice for your family.

Emergency Rooms

In a moment of uncertainty, the ER is often the first choice. ERs offer the most comprehensive care, yet few pediatric patients need the full scope of services. All, however, face considerable costs and wait times.

A 2010 study by Health Affairs estimates that many ER visits (not just pediatric visits) could be managed at urgent care centers or retail clinics, with estimated savings totaling $4.4 billion. Unnecessary visits span a range of minor conditions, from simple illnesses to fractures.

In the current healthcare landscape, there are two types of ERs: hospital ERs and freestanding ERs.

Hospital ERs

Are physicians on staff? Yes Are pediatric specialists on staff? Sometimes
How do relative costs compare? Highest How does relative wait compare? Highest
Can you get X-rays and treat pediatric fractures? Yes Is there direct hospital admission? Yes

Hospital ERs are “typical” ERs: points of triage, treatment, and, if necessary, admission to adjoining hospitals. For pediatric emergencies, ERs are the first choice for serious head injuries, overdoses, and other major health events. ERs also see patients because of round-the-clock services and federal laws that require ERs to stabilize and examine all patients, regardless of their ability to pay.

For ER visits that fall below the threshold of serious injury or life-threatening illness, the negatives of an ER visit can pile up quickly. In particular, pediatric ERs—typically a dedicated area within a standard ER—have longer wait times, averaging 40 minutes to see a physician, compared to 25 minutes at a standard ER. Total stays average 130 minutes, compared to 98 at a standard ER. At any ER, the most urgent cases receive immediate treatment. Those arriving for minor illnesses are likely to experience longer wait times.

Within pediatric ERs, non-urgent conditions account for 58–82% of all visits. Additional studies note that 96% of all pediatric ER visits result in treatment and release, not hospital admission. Many of these unnecessary ER visits are prompted by dissatisfaction with a primary care provider or available appointment times, rather than severity of illness.

Our relationship with area hospitals and reputation for expert pediatric care allow us, in the rare instances it’s necessary, to admit pediatric patients directly. For the vast majority of cases, we provide quicker, less expensive treatment in a facility designed for children and staffed by pediatric experts.

– Dr. Mark Flanzenbaum, KidMed

In ERs without a pediatric wing, children are less likely to be seen by a physician with extensive pediatric training. Inability to diagnose the seriousness of pediatric conditions can lead to unnecessary hospital admission. A Canadian study found that children diagnosed with bronchiolitis in general ERs were twice as likely to be admitted as those diagnosed in pediatric ERs.

Costs are higher as well. ERs charge a facility fee, often in excess of $1,000, to recoup added expenses of 24-hour staffing and expensive medical equipment. Hospitals and ERs also charge patients differently than urgent care centers, with a-la-carte pricing that adds costs for each medical professional involved, procedure performed, and pill dispensed.

Pediatricians further note that unnecessary visits to the ER have an impact beyond added costs and wait times. They also expose children to illnesses of other ER patients.

Freestanding ERs

Are physicians on staff? Yes Are pediatric specialists on staff? Rarely
How do relative costs compare? High How does relative wait time compare? Average
Can you get X-rays and treat pediatric fractures? Yes Is direct admission to a hospital possible? Yes

Freestanding ERs, which have proliferated in recent years, are defined by the American College of Emergency Physicians as facilities that are “structurally separate and distinct from a hospital and provide emergency care.” Freestanding ERs differ from urgent care centers primarily by access to a CT scanner and ultrasound—services few patients need. Most do not staff pediatricians.

Freestanding ERs first appeared as extensions of hospital systems in Texas. Texas allowed freestanding ERs to operate without a hospital affiliation beginning in 2010. Today, there are more than 200 throughout the United States, including Virginia.

The growth of freestanding ERs has been predicated on delivery of emergency care in rural areas that, financially, cannot support a full hospital. However, a study by Brigham and Women’s physician Jeremiah Schuur found the opposite to be true—that freestanding ERs were not located in poor, rural areas but had instead located exclusively in wealthy, well-insured communities.

Because high-quality insurance policies often include small copays of $50 or $100 for an ER visit, parents are not incentivized to seek care for their children at less expensive outlets like urgent care. Filings from First Choice, the largest freestanding ER chain, show average patient billings of $1,500 among the more than 77,000 treated in 2015.

Insurance companies footed most of the bill, but there were also unexpected surprises: small upfront costs with large bills arriving in the mail weeks later. The growth of high-deductible insurance policies has made consumers increasingly likely to bear the cost of these unexpected charges.

Insurance policies have continued to pay the high cost—tied largely to facility fees—while most patients remain unaware of the added expensive. State laws typically require insurers to cover ER visits if the patient or parent perceives an emergency, making it difficult for insurance companies to deny claims from freestanding ERs.

Urgent Care

The Urgent Care Association of America (UCAA) estimates that there are some 9,000 urgent care centers across the United States. (Others suggest the figure may be lower, around 6,000.) Urgent care has eluded a formal definition, although criteria for accreditation by the UCAA include “evaluating walk-in patients of all ages for a broad spectrum of illness, injury and disease,” as well as on-site X-ray and phlebotomy services, performance of minor procedures, and availability seven days per week.

The general level of treatment—access to X-rays, basic laboratory testing, suturing—is not different between general urgent care and pediatric urgent care. When a primary care provider is not available to see your child, after-hours urgent care provides cost-effective treatment for most ailments. However, not all urgent care centers perform all services in every situation, with some excluding procedures like facial sutures or certain treatments for especially young children.

Health Affairs cities studies that show costs at urgent care or retail clinics typically are $228–$460 less than comparable care at ERs. Unlike ERs, urgent care facilities are not required to accept Medicaid or uninsured patients. (KidMed accepts Medicaid and offers self-pay and flexible payment options.)

General Urgent Care

Are physicians on staff? Usually Are pediatric specialists on staff? Rarely
How do relative costs compare? Lower How does relative wait time compare? Lower
Can you get X-rays and treat pediatric fractures? Sometimes Is direct admission to a hospital possible? Rarely

Typically, general urgent care centers are not staffed by physicians, physician assistants, or nurse practitioners with extensive pediatric expertise.

The end result, according to Johns Hopkins pediatric emergency physician Therese Canares, is that “because many urgent-care providers are not comfortable treating certain pediatric cases, they preemptively triage them to the emergency department, even when these kids clearly don’t need emergency care.”

A Rhode Island Medical Journal study into the treatment of pediatric patients at general urgent care centers found three common scenarios that challenged general urgent care providers:

  • acutely ill young infants
  • children with minor traumatic brain injury
  • uncooperative children requiring minor procedures

The study, based on interviews with nine general urgent care providers, revealed provider concerns that, with nonverbal infants, providers might be “missing something.” This concern often reduced the primary goal to stabilizing the infant, then transferring the child to the ER or coordinating follow-up care with a primary care provider.

At general urgent care, young children with minor hydration or breathing issues often are referred to the ER because staff lack pediatric experience to treat the issue confidently.

– Dr. Mark Flanzenbaum, KidMed

In the case of head injuries, surveyed providers believed any sign of abnormal mental status, such as confusion or slurred speech, warranted ER transfer for a CT scan. Without pediatric expertise to assess the seriousness of the injury confidently, concerns for intracranial injury outweighed the risk of radiation exposure.

Procedures also presented challenges to general urgent care providers. Providers either were unfamiliar with or, due to staffing limitations, unable to carry out minimal sedation and pediatric-restraint techniques for exceptionally young or uncooperative children requiring stitches or reduction of a dislocation.

Pediatric Urgent Care

Are physicians on staff? Yes Are pediatric specialists on staff? Yes
How do relative costs compare? Lower How does relative wait time compare? Lower
Can you get X-rays and treat pediatric fractures? Yes Is direct admission to a hospital possible? Yes

Whether at an ER or urgent care, physicians, physician assistants, nurse practitioners, and support staff all have medical expertise. At pediatric urgent care centers, that expertise is dedicated to diagnosing and treating children, from newborns to age 21.

Capabilities, including suturing and X-rays, are consistent in general urgent care and pediatric urgent care centers—but only pediatric urgent care centers treat the full range of pediatric illnesses and injuries. Further, pediatric urgent care differs in execution, with a practice centered on a specific patient type with specific needs.

Kids are not just little adults. Their illnesses and injuries are often quite different and need to be diagnosed and treated diferently.

– Dr. Mark Flanzenbaum, KidMed

Accurate diagnosis avoids unnecessary ER transfers and recognizes serious issues quickly. Experience in pediatric treatment ensures care from providers with expertise in a range of sedation methods and other techniques to make procedures more effective, less stressful, and less painful.

Pediatric expertise is not the only benefit. As with general urgent care, the cost of care is far less. Emergency rooms are expensive because of 24-hour staffing and equipment that is unnecessary for the vast majority of cases.

Retail Clinics

Are physicians on staff? No Are pediatric specialists on staff? No
How do relative costs compare? Lowest How does relative wait time compare? Lowest
Can you get X-rays and treat pediatric fractures? No Is direct admission to a hospital possible? No

The first retail clinics opened in 2000. By definition, retail clinics are located within retail stores, including pharmacies, supermarkets, and hypermarkets. Most are owned by the store in which they’re located. (CVS acquired MinuteClinic, the largest in-store clinic operator, in 2006.) Others are operated through partnerships or by independent healthcare providers.

While often chosen for their convenience—nearly one-third of the U.S. population lives within 10 minutes of a clinic—the scope of retail clinics is limited.

More than 95% of all cases fall into four categories:

  • 61% upper-respiratory infections
  • 21% vaccinations and preventative exams
  • 5% allergies, insect bites, rashes, and conjunctivitis
  • 7% urinary tract infections

Diagnosis is menu driven, with a rigid “if, then” diagnostic protocol. Retail clinics cannot perform X-rays, procedures, or lab testing, apart from a handful for point-of-care tests for illnesses.

Cost is cited as a benefit of retail clinics, and studies suggest that costs are slightly lower than those at other facilities. A $110 visit to a retail clinic typically costs $156 at urgent care, $166 at a primary care physician’s office, and $570 at an emergency room, according to an Annals of Internal Medicine study. Insurance providers view retail clinics as an opportunity to lower healthcare costs, and some insurers have reduced or eliminated copays at retail clinics.

Costs are lower, in part, because staffing needs are less, with a physician assistant or nurse practitioner managing care through a structured protocol. The American Medical Association and American Academy of Pediatrics have voiced concerns about the quality of care; physician assistants and nurse practitioners typically work under physician oversight.

Others have voiced broader concerns about the overall “fracturing” of care among many providers, especially for effective management of chronic conditions. Lack of follow-up has been cited as another limitation of retail clinics.

Physician groups and others have also expressed concerns about overprescribing, as many retail clinics are located in and owned by pharmacies. Research has not shown an increased rate of antibiotic prescription in retail clinics, although few studies have been conducted.

 

  • This field is for validation purposes and should be left unchanged.

Categories: Resources

Comments

Respond

Your email address will not be published. Required fields are marked *.

Comments support these HTML tags and attributes:
<a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <s> <strike> <strong>